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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610007
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:11:37 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240729092217
FACILITY NAME:VARENITA OF SIMI VALLEYFACILITY NUMBER:
567610007
ADMINISTRATOR:VEIS, MARGIEFACILITY TYPE:
740
ADDRESS:3921 COCHRAN STREETTELEPHONE:
(805) 327-1100
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:110CENSUS: 106DATE:
08/29/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Margie VeisTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility does not have adequate supplies

Staff did not meet residents’ diapering needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit to continue investigation for the allegations listed above. Upon arrival LPA met with Nancy Nelson and explained the reason for the visit.

On 08/02/2024, from 12:00 p.m. – 02:45 p.m., LPA’s Brian Balisi and Trevor Byrne initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff as well as reviewed and obtained pertinent documents relevant to the investigation.

It was reported that "Facility does not have adequate supplies" as it was alleged that they have an insufficient PPE supply. Interviews conducted with eleven (11) staff revealed that all (11) have always observed a sufficient supply of PPE. During physical plant, LPA observed a sufficient supply of PPE located in a supply closet next to the medication room in memory care, in the memory care director's office, in the Executive Director's office, a supply closet on the 2nd floor and at the front desk receptionist area
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20240729092217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
VISIT DATE: 08/29/2024
NARRATIVE
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Continued from 9099

LPA's interview with five (5) families / responsible parties of residents in care revealed that all (5) did not express any potential or immediate concerns that the facility did not have an adequate supply of PPE. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Facility does not have adequate supplies” is deemed Unsubstantiated at this time.

It was reported that "Staff did not meet residents' diapering needs", as it was alleged that diapers that were used were too small for most residents and it left marks. Interviews conducted with eleven (11) staff revealed that all (11) have always observed residents using the correct size of diapers and all (11) stated they have never observed any diapers leave marks on any residents. LPA's interview with five (5) families / responsible parties of residents in care revealed that all (5) did not express any potential or immediate concerns of incontinent being too small and leaving marks on the residents. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not meet residents’ diapering needs” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240729092217

FACILITY NAME:VARENITA OF SIMI VALLEYFACILITY NUMBER:
567610007
ADMINISTRATOR:VEIS, MARGIEFACILITY TYPE:
740
ADDRESS:3921 COCHRAN STREETTELEPHONE:
(805) 327-1100
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:110CENSUS: 106DATE:
08/29/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Margie VeisTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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2
3
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5
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8
9
Staff used expired COVID tests to test residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit to continue investigation for the allegations listed above. Upon arrival LPA met with Nancy Nelson and explained the reason for the visit.

On 08/02/2024, from 12:00 p.m. – 02:45 p.m., LPA’s Brian Balisi and Trevor Byrne initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff as well as reviewed and obtained pertinent documents relevant to the investigation.Today LPA conducted physical plant, interviewed staff and interviewed represeantives of ACON Labs Inc.

It was reported that "Staff used expired COVID tests to test residents" as it was alleged that the COVID tests that staff were using were expired. Interviews conducted and records reviewed revealed on August 9, 2024 a Flowflex COVID test kit (Lot # COV2020158) was used to test a resident.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240729092217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
VISIT DATE: 08/29/2024
NARRATIVE
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Continued from 9099-A

LPA's interview with Executive Director Margie Veis revealed that on August 9, before using the test kits they contacted Ventura Public Health to inform them of the expiration dates. Ventura County Public Health advised them to contact the manufacturer of the Flowflex COVID test kit, ACON Labs Inc. Interview with Veis further revealed that they spoke with a representative of ACON Labs Inc and informed them of the expiration date of 02/22/2023 and Veis stated that the representative told them the test kits are still good for two (2) years. Facility staff proceeded to use test kit on one resident, which resulted in a positive test. Upon further research facility staff observed the LOT# (COV2020158) on the Food and Drug Administration (FDA)'s website, which confirmed that the COVID test kits expired in February 2024 based on the Lot # and expiration date. Veis called manufacturer back to gain clarification on the discrepancies and the representative informed them that expiration is 2 years from manufacturing date versus the expiration date. Staff immediately discarded their current supply of COVID test kits and obtained new ones from Ventura County Public Health.

LPA's interview with representatives from ACON Labs Inc., the maker of the Flowflex COVID test kit, revealed that the test kits with the specific LOT # should not have been used after February 2024, as their results would be invalid. LPA also reviewed records from the FDA's website, which confirmed that the COVID test kit (LOT#COV2020158) expired in February 2024. Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine the allegation occurred. Therefore, the allegations that “Staff used expired COVID tests to test residents” has been deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240729092217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by
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POC cleared during visit. Licensee has discarded expired test kits and LPA observed new COVID test kits in storage. No further action required.
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Based on observations and interviews, the Licensee did not comply with the section cited above, as expired COVID test kits were used to test residents, which poses a potential personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5